Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the preferred first-line non-insulin agent in patients with ketosis-prone diabetes during "remission" and evidence of preserved beta cell function?
Ketosis-prone diabetes (KPD) is an atypical form of diabetes that has been found in various racial and ethnic groups (Asian Indian, South American, West African, African American and others). People with KPD may present with DKA without the autoimmune findings of Type 1 diabetes. After the DKA episo...
Should we be more cautious with the use of GLP 1 R agonist therapy in patients with Type 1 diabetes mellitus and obesity given the increased risk of cardiovascular disease with high body weight variability?
There doesn't seem to be any evidence that GLP-1 RA would increase the risk of CV disease. Biologically, the benefits that have been shown in patients without Diabetes (the SELECT trial) should still be applicable for patients with Diabetes Type 1.The trials that didn't show much efficacy in glucose...
When managing patients with suspected MASLD, what specific criteria or findings would prompt you to refer them to hepatology?
In patients with suspected MASLD, I consider referral to hepatology when there is evidence of fibrosis by elastography or if I don't see improvements in related parameters with weight loss and/or medical therapies (GLP1-related meds, SGLT2i, TZDs).
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
How do you approach workup and management of hyperhidrosis?
Oral anticholinergics
Would you consider the use of low-dose naltrexone in patients with fibromyalgia and/or type 2 lupus symptoms?
Yes, I think it is worth trying low-dose naltrexone in fibromyalgia - seems safe and may be effective.
What is your approach to initiation of mirtazapine for appetite stimulation and depression in older adults, both in terms of starting dose and titration?
I consider initiation of mirtazapine for older adults who could benefit from at least two of the three potential effects of mirtazapine - improvement of mood, appetite, and/or sleep. I always start at a low dose of 7.5 mg nightly, potentially uptitrating to 15 mg nightly after a week or two if the m...
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.